Documentation, Coding, Payment, and Compliance: Managing for Success in the Outpatient Physical Therapy Environment

Robbie B. Leonard, PT, DPT

Course Description

This module will present to the physical therapy clinical doctoral learner methods to remain current in issues related to the documentation, coding, billing, and payment, for physical therapy services in all outpatient settings. Compliance issues are also covered throughout the course materials either specifically or in context with the topic being covered during each module. This information is critical to being successful in the administrative aspect of providing physical therapy as well as the delivery of clinical services. Understanding and being able to apply this information is vital in order to thrive in today’s healthcare environment due to the transition in payment methodologies and the focus moving away from a procedure based reporting and payment mechanism to payment and service delivery models that are emphasizing not only the reporting of services reflecting the severity of the patient’s condition(s) but also the outcomes of your clinical decision making. The content covered in this course includes information that will assist the physical therapist in their day to day practice operations, from an administrative perspective and provide resources for them as informed physical therapy professionals.

This is the most up-to-date information to improve your clinic and allow you the abilty to maximize your reimbursement while maintaining complete compliance with all current laws and regulations.

 

Objectives

  • Explain the process involved in the development and maintenance of AMA’s CPT codes, including the use of modifiers, as applied to physical medicine and rehabilitation services.
  • Describe the appropriate application of current CPT code to clinical services, coding challenges, and possible reimbursement implications.
  • Critically assess the developmental process of the Resource Based Relative Value Scale (RBRVS) and its impact on payers outside of the Medicare program.
  • Understand the components of RBRVS and how they impact the payment for services.
  • Understand the methodology and calculation of the Medicare Fee schedule and its impact on fee schedules developed by private payers.
  • Understand the current use of diagnosis codes both current (ICD-9) and future (ICD-10) and their impact on the reimbursement process and ability to support medical necessity.
  • Understand the various aspects of payment policy that apply to the Medicare program and how they influence policies of private payers, including mechanics and importance of reporting on quality measures and functional limitations.
  • Understand the current legislative initiatives and regulatory environment and the impact on payment for outpatient rehab services both now and in the future.
  • Recognize the concepts of fraud and abuse and understand health care environmental factors that influence the occurrence of fraudulent and abusive.
  • Understand the federal False Claims Act and its importance determining what constitutes fraud and abuse violations in health care practices.
  • Apply clinical reasoning and quality assurance strategies to documentation supporting medical necessity of physical therapy and avoid potential fraud and abuse situations.
  • Be able to use an understanding of the health care environment from the perspective of the provider and the third-party payer to effectively manage in the outpatient rehab setting in the areas of coding, billing, documentation for medical necessity and compliance.
  • Understand the importance of physical therapist involvement in peer review and utilization management strategies.
  • Understand audit review flags and assess how these flags alert reviewers to potential problems with the provision or billing of physical therapy services.
  • Describe the proposed structure and underlying premise of the alternative payment methodology being considered for physical therapy services in the future.

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